Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medina Nursing Center during CMS and state inspections, most recent first.
Failure to identify new foot wounds and complete weekly wound assessments. A resident with cellulitis, PVD, lymphedema, obesity, and CHF had daily dsg changes to bilateral lower-leg wounds, but staff did not document measurements or identify new wounds on the feet/toes until maggots were found between the toes of the left foot. Only one weekly wound assessment was completed, it lacked measurements and toe details, and staff did not notify the MD/NP of the new findings before the resident was hospitalized for left-foot cellulitis.
Failure to implement and document fall interventions for two residents with repeated falls. One resident with neurocognitive disorder, severe functional dependence, and a POA request to be brought directly from meals to his recliner was left unattended in the lounge and later fell; staff also left him unattended with his bed raised and fall mats moved, leading to another fall. A second resident with severe cognitive impairment had multiple falls over several months, but the care plan showed no added interventions and the DON stated there were no formal fall investigations.
A resident with dementia and multiple comorbidities, care planned as a fall risk with a sensor pad alarm when unattended in bed or chair, experienced two falls in which the personal alarm did not sound. In both events, staff found the resident on the floor and later determined the alarm was not working until batteries were replaced and, in one case, a worn wire was adjusted. CNAs reported that low-battery warning behaviors were known and that repeatedly resetting alarms could lead to dead batteries without staff awareness. The ADON was unaware of the two alarm-related falls, and the resident’s fall care plan was not reviewed or revised to reflect these actual falls or any additional fall-prevention interventions.
A resident with severe cognitive impairment and multiple comorbidities sustained a second-degree burn to the knee after coming into contact with a radiator heating unit positioned directly next to the bed. Staff found the resident's knee resting on the heater, which had a surface temperature of 126°F. The bed was routinely placed very close to the heater, creating an accident hazard that was not addressed prior to the incident.
A resident who was cognitively intact experienced verbal abuse when a CNA, while assisting with morning care, used loud, vulgar, and offensive language during a phone conversation in the resident's presence. The resident felt intimidated and reported the incident, which was substantiated through staff interviews and facility investigation.
A dependent resident with significant medical conditions was left outside in the sun for two hours without water or a way to call for help, due to staff failing to provide required supervision and monitoring. The resident was found unresponsive, suffering from heat exhaustion, sunburn, hypoxia, and altered mental status, and required hospitalization. Staff interviews revealed confusion about responsibility for monitoring and a lack of communication, with the resident unable to signal for assistance or access hydration.
A resident with severe cognitive impairment and multiple health issues was subjected to verbal abuse by a CNA, who used explicit and derogatory language in the resident's presence. The incident was witnessed by another CNA, who reported the behavior to the ADON after leaving her shift early due to discomfort. Facility records and surveillance footage confirmed the occurrence of verbal abuse, in violation of facility policy.
A resident with severe cognitive impairment was subjected to verbal abuse by a CNA, which was witnessed by another CNA on her first day. The witnessing CNA did not immediately report the incident as required by facility policy, instead notifying the ADON later via text. Documentation and interviews confirmed a delay in reporting the abuse allegation.
A resident with multiple medical conditions and who was cognitively intact reported $80 missing from her purse after a visitor, identified as another resident's family member, entered her room multiple times without a valid reason. Video surveillance and staff interviews confirmed the unauthorized entries and substantiated the theft, which was classified as misappropriation of resident property and abuse.
A resident with dementia and severe agitation, identified as a high elopement risk and equipped with a departure alert system, was able to leave the facility unsupervised after the alarm system failed to activate. Staff were aware of the resident's exit-seeking behavior but did not increase supervision, and a caregiver from a neighboring building transported the resident offsite without notifying facility staff.
A CNA observed significant bruising on a resident's arm, wrist, and hand during morning care but did not report it immediately, only notifying the Social Services Director later in the day. Facility policy requires immediate reporting of injuries of unknown origin, such as bruises.
A resident with significant muscle weakness and chronic pain, who requires one-person assistance and a gait belt for transfers, sustained a large bruise on her forearm after a CNA pulled her by the arm during a nighttime transfer instead of using the gait belt as required by her care plan and facility policy. Staff interviews and the resident's account confirmed that proper transfer procedures were not followed, resulting in injury.
Surveyors found that food items in the kitchen refrigerator, including deli meats and potato salad, were not labeled with open or use by dates, and some items were past their use by date or were personal staff food stored with resident food. The dietary manager confirmed these items should have been discarded and that facility policy requires proper labeling and disposal of improperly stored food.
A resident with multiple medical conditions was provided with a pommel cushion and non-slip fabric in a reclining wheelchair to prevent sliding and falls, but staff failed to assess the need for the device, obtain a physician's order, or document its use in the care plan. The DON was unaware of the intervention, and facility policy requiring assessment, consent, and orders for physical restraints was not followed.
Surveyors found that two residents had insulin vials in use for over 30 days and an insulin pen without an open date label, contrary to facility policy and manufacturer guidelines. A registered nurse confirmed that insulin should be labeled with the date opened and discarded after 27 days.
A resident who was eligible for a PCV20 pneumococcal vaccine was not documented as being offered or having consented or refused the vaccine, despite facility policy requiring annual vaccine offers and documentation of resident wishes.
A resident with shingles was not consistently managed under appropriate infection control measures. Despite being on contact precautions, visitors and staff entered the room without PPE, and there was no PPE available outside the room. The facility's policy required contact precautions until lesions were crusted or healed, but this was not consistently followed, leading to a deficiency in infection control practices.
Two residents were involved in incidents due to improper transfer practices. One resident was hit in the face by a mechanical lift when a CNA mistakenly pulled the emergency release. Another resident fell and hit her head during a transfer without a gait belt, despite it being required in her care plan. The facility's policies emphasize the use of mechanical lifts and gait belts for safe transfers.
A resident sustained a forehead laceration due to improper use of a mechanical sling lift by two CNAs. The lift tilted during a transfer, causing a bolt to injure the resident's head. The facility's policy requires one staff to manage the lift and another to support the resident, but this was not adhered to, resulting in the incident.
Failure to Identify New Foot Wounds and Complete Weekly Wound Assessments
Penalty
Summary
The facility failed to identify a resident’s new, non-pressure wounds and failed to complete weekly wound assessments on the resident’s wounds. The resident was admitted with diagnoses including cellulitis of both lower legs, peripheral vascular disease, lymphedema, obesity, and CHF, and was receiving daily dressing changes to bilateral lower leg wounds for cellulitis. The records showed redness, swelling, open areas, and drainage to the lower leg wounds, but no wound measurements were documented and no wounds to the resident’s left foot or toes were documented in the daily notes during the period reviewed. Only one weekly wound assessment was completed during the review period, and that assessment documented wounds to the posterior and anterior bilateral lower legs as well as wounds to the toes on both feet, but it did not include measurements or identify which toes were involved. The assessment also did not document that the physician or NP were notified of the wounds. Staff interviews showed the resident’s feet and toes were swollen and red, and one RN stated she did not recall whether she looked between the resident’s toes during the assessment. Another RN stated the resident complained of left foot and toe pain during dressing changes but no physician or NP was notified. On a later dressing change, nursing staff found multiple maggots in new wounds between the first and second toes and between the third and fourth toes of the resident’s left foot, and the resident was sent to the hospital. Hospital records showed admission for cellulitis of the left foot. The resident stated he had increased pain in the left foot for about a week before the wounds were found and did not know how long the wounds with maggots had been present. The facility policy required wounds to be assessed and documented upon identification and at least weekly, and required notification of the PCP or wound nurse when skin breakdown was identified.
Failure to implement and document fall interventions for residents with repeated falls
Penalty
Summary
The facility failed to implement fall interventions and update the care plan for a resident with a history of repeated falls. The resident’s record showed diagnoses including neurocognitive disorder, repeated falls, aphasia, and failure to thrive. The resident’s MDS showed severe cognitive and functional impairment, use of a walker and wheelchair, range of motion limitations to both arms, and dependence on staff for transfers and walking. A family meeting documented the POA’s request that the resident be brought directly from meals to his room and placed in his recliner rather than left in the lounge, and nursing and social services agreed to those goals. After that meeting, the resident had a fall in the lounge and later another fall in the lounge after being placed there following the evening meal. The fall note for the later event showed the resident was found with superficial scratches to his left arm and a bump on his forehead, and the POA declined ED evaluation. During interview, the RN stated the resident had been placed in the lounge after the meal and was not supervised, and staff were not aware he was not to be left unattended in the lounge. The DON stated the instruction not to leave the resident unattended and to place him in his recliner was a fall intervention requested by the POA, that the information had been disseminated to staff, and that it should have been in the care plan before the fall but was not entered until the day after. The resident also had a fall from bed when staff left him unattended while his bed was raised and the fall mats had been moved away. The CNA stated she left the resident briefly to gather supplies and acknowledged she should have lowered the bed and replaced the mats before stepping away. The RN stated the bed was at working height, the mat was not underneath the resident, and the CNA should have gathered all supplies before leaving because the resident had fallen many times. The DON stated that if staff walk away, they must lower the bed and put the fall mats in place to prevent injury or minimize severity. A second resident with severe cognitive impairment and substantial to maximal dependence for most care had 10 falls over several months. The resident’s record included multiple falls involving sliding from a wheelchair, falling while attempting to toilet, falling in the hallway, and falling in the room, with some events unwitnessed and others witnessed by staff or another resident. The resident’s care plan, initiated months earlier, identified fall risk related to dementia, CHF, asthma, and type 2 diabetes, but it showed no interventions added after initiation. The DON stated the facility discussed falls in meetings, used alarms and different chairs, tried a Broda chair, and considered toileting programs and activity, but also stated she did not have any formal fall investigations and that she did not think the resident’s chair was placed on the care plan.
Failure to Maintain Functional Personal Alarm and Update Fall Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s personal alarm was functioning despite the resident being identified as at risk for falls. The resident had multiple medical conditions, including dementia, congestive heart failure, asthma, type 2 diabetes mellitus, dysthymic disorder, chronic kidney disease, arthropathy, benign prostatic hyperplasia, hypercholesterolemia, gastroesophageal reflux disease, obstructive sleep apnea, hyperparathyroidism, peripheral vascular disease, and hypertension. His care plan, dated 12/8/25, identified him as at risk for falls and required a sensor pad alarm to be in place when he was left unattended in bed, a chair, or a wheelchair. On 1/10/26, the resident experienced an unwitnessed fall in the bathroom; he was found on the floor in a supine position, unable to state what happened, and his alarm was noted to be not working. A CNA reported that the same alarm device was moved between the resident’s bed and chair and that he always had an alarm to alert staff when he tried to get up, as he liked to attempt getting up on his own and fell. An RN stated that on the date of the fall the alarm was not working, and that after she and a CNA replaced the batteries and manipulated the worn wire, the alarm started working. A second fall occurred on 1/23/26, when the resident was found on the floor with his back against his room door, leaning on his right elbow with his legs stretched out, and again his alarm did not sound. The resident stated he was going to the bathroom. A CNA who worked that shift reported that the nurse found the resident on the floor and that the alarm was not going off until the batteries were replaced. The CNA also stated that staff can tell when alarm batteries are going low because some alarms start beeping rapidly or make a humming noise, and that if staff keep resetting the alarm when this happens, the batteries will die and staff will not be aware. The Assistant Director of Nursing stated she was not aware that the resident had two falls in which it was documented that his alarm was not working, and confirmed that the alarm should be working because it is an intervention for falls. The resident’s care plan, dated 12/8/25, was not reviewed or revised to reflect the two actual falls in January 2026 or any changes made for fall prevention, despite the facility’s fall policy stating that residents are to be assessed and fall situations evaluated to identify risk factors and develop individualized interventions.
Resident Burn Injury Due to Bed Placement Near Heater
Penalty
Summary
A dependent resident with severe cognitive impairment and multiple medical diagnoses, including dementia and congestive heart failure, sustained a second-degree burn to his left knee while in bed. The resident was assessed as being at moderate risk for skin breakdown and was dependent on staff for all care. The incident occurred when the resident's knee came into contact with a metal radiator heating unit located directly next to his bed, which was positioned parallel and in close proximity to the heater. The heating unit's surface temperature was recorded at 126 degrees Fahrenheit. Staff interviews and observations revealed that the resident's bed was typically placed very close to the heating unit, with only a small space between the bed and the heater, making it difficult for staff to access the area. On the day of the incident, staff found the resident lying on his side with his knee resting on the heater. The resident did not report pain, but staff observed redness, a popped blister, and serosanguinous drainage on the knee. The resident was known to move himself in bed, sometimes repositioning himself after staff had assisted him. The facility's policy required employees to exercise maximum care and good judgment to prevent accidents and injuries, and to report unsafe conditions. However, the arrangement of the resident's bed in close proximity to a high-temperature heating unit created an accident hazard that was not addressed prior to the incident, resulting in the resident sustaining a burn injury.
Verbal Abuse by CNA During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) engaged in verbally abusive behavior toward a cognitively intact resident while assisting her with morning care. The CNA entered the resident's room wearing earphones and was loudly conversing on the phone, using vulgar and offensive language, including repeated use of profanities and religious expletives. The resident, who was alert and able to recall the incident, reported feeling confused, intimidated, and personally offended by the language and the CNA's angry tone. She expressed fear of potential retaliation and reported the incident to staff to prevent similar occurrences with other residents. Staff interviews and documentation confirmed that the incident was promptly reported to nursing and social services. The CNA was observed on camera using her phone in the hallway outside the resident's room, though the audio was not captured. The facility's policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents, regardless of their ability to comprehend. The investigation substantiated the resident's account, confirming that the CNA's conduct constituted verbal abuse and failed to provide the resident with the attention and respect required.
Resident Left Unattended Outside Resulting in Hospitalization for Heat-Related Illness
Penalty
Summary
A dependent resident with multiple medical conditions, including rheumatoid arthritis, major depressive disorder, encephalopathy, acute kidney failure, and peripheral vascular disease, was left outside in her reclining wheelchair for two hours without water or a means to call for help. The resident was entirely dependent on staff for all activities of daily living and mobility, as documented in her care plan. On the day of the incident, she was placed directly in the sun after lunch, and staff failed to provide the required supervision and monitoring. Staff interviews revealed that the usual practice was to set a timer for 10-20 minutes when the resident was taken outside, with checks at those intervals due to her inability to signal for assistance or return inside independently. However, on this occasion, there was confusion and lack of communication among staff regarding who was responsible for monitoring the resident and whether a timer had been set. Multiple CNAs stated that the resident did not have water with her and could not hold a drink, and there was no call light or device for her to request help. The resident was not in direct view of the door, and staff were unaware of her presence outside until she was found unresponsive by another CNA. Upon discovery, the resident was unresponsive, with her eyes rolled back and twitching, and was noted to be red, hot, and very thirsty. Immediate interventions included providing water, applying cold compresses, and administering oxygen. She was subsequently transferred to an acute care hospital, where she was treated for heat exhaustion, sunburn, hypoxia, altered mental status, and dehydration. Hospital records confirmed sunburn to her face, neck, and chest, hypoxia, and improvement after IV fluids. The facility's policy required 15-minute checks for residents outside, but this was not followed, resulting in the resident's prolonged exposure and subsequent hospitalization.
Removal Plan
- An assessment form was created and implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed if there is any change in condition. Audits will be completed by DON or designee.
- Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. The policy includes identifying safety measures and resident assessment, timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, checks, notes regarding resident, hydration offered, time coming in, and staff signature.
- All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminate to their staff. Agency staff will be educated on arrival by DON or designee.
- Policy states that whoever takes the resident outside is the one responsible to ensure check is conducted. A timer is set to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the check, the resident is brought back in to the facility.
- Audits will be conducted by DON or designee.
Verbal Abuse of Cognitively Impaired Resident by CNA
Penalty
Summary
A resident with severe cognitive impairment and multiple medical conditions, including malignant neoplasm of the prostate, acute posthemorrhagic anemia, severe protein calorie malnutrition, depression, hypertension, muscle wasting, and dysphagia, was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The incident occurred when a newly oriented CNA entered the resident's room to assist with a transfer and witnessed another CNA using foul language and derogatory terms toward the resident, including explicit language referencing the resident's status as a veteran. The resident responded by asking for help and expressing that he was not treated well at the facility. The witnessing CNA reported feeling extremely uncomfortable and left her shift early, later notifying the Assistant Director of Nursing (ADON) about the incident. Facility records and interviews confirmed that the abusive language was used in the resident's presence and that the incident was corroborated by surveillance footage. The facility's investigation found sufficient evidence of verbal abuse, as defined by their policy, which prohibits disparaging or derogatory communication toward residents. The incident was reported and documented, and the staff member involved was identified as having violated facility policy regarding resident abuse.
Failure to Immediately Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse was reported immediately for one resident who was severely cognitively impaired and dependent on staff for care. On the first day of work, a CNA witnessed another CNA using foul and derogatory language toward the resident during care, which made the resident visibly distressed and prompted the witnessing CNA to leave her shift early. The CNA reported her concerns to the Assistant Director of Nursing (ADON) later that day via text message, rather than immediately notifying the floor nurse, social services, or other appropriate personnel as required by facility policy. Facility records show that the incident was not reported until several hours after it occurred, despite clear orientation training on abuse reporting procedures. The facility's policy mandates immediate reporting of abuse allegations to nursing, the Administrator, and Social Services to ensure prompt investigation and notification of necessary agencies. The delay in reporting was confirmed through interviews and documentation, and surveillance footage corroborated the account of verbal abuse occurring in the resident's room.
Failure to Protect Resident from Theft by Visitor
Penalty
Summary
A resident, who was cognitively intact and had multiple medical diagnoses including protein-calorie malnutrition, cancer, anxiety, osteoporosis, adult failure to thrive, and major depressive disorder, reported that $80 was stolen from her purse while residing in the facility. The resident stated she had attempted to give the money to her daughter, who refused it, and then placed the money in her wallet, which was kept in her purse hanging on a hook inside her room. The resident discovered the money missing when preparing to go out with friends and immediately reported the theft to staff, who searched her room but could not locate the missing funds. Facility staff initiated an investigation, which included reviewing video surveillance footage. The footage revealed that a visitor, who was the grandson of another resident, entered the resident's room multiple times over a short period. Initially, the visitor was given the wrong room number by a CNA and entered the resident's room by mistake. However, after being directed to the correct room, the visitor returned to the resident's room several more times without a legitimate reason, as confirmed by both staff interviews and video evidence. The visitor was identified by his grandfather and another family member present at the facility. The facility's investigation concluded that the resident was a victim of misappropriation of property, which constitutes abuse. The suspected individual was not affiliated with the facility but was a family member of another resident. The resident expressed embarrassment over the incident and did not wish to press charges. Staff and social services substantiated the theft and classified it as abuse, confirming that the resident's belongings were not adequately protected from wrongful use by visitors.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Alarm Malfunction
Penalty
Summary
A resident with diagnoses including dementia with severe agitation, anxiety disorder, and hypertension was admitted to the facility and identified as a severe elopement risk. The resident was independent with ambulation and was equipped with a departure alert system on her wrist. Despite these precautions, the resident was able to leave the facility unsupervised and was later found at her daughter's house. The facility's incident investigation revealed that staff became aware of the resident's absence after a CNA questioned her whereabouts over the walkie, prompting a search of the facility and surrounding areas. Interviews with staff indicated that the resident had been displaying exit-seeking behaviors on the morning of the incident, including packing her bags and expressing a desire to go home. Although the DON and nursing staff were aware of her agitation, enhanced supervision such as 1:1 monitoring or frequent checks was not implemented. The departure alert system, which was intended to notify staff if the resident attempted to leave, did not activate when the resident exited the building. Staff had previously checked the system and believed it was functioning, but it failed to alert them during the incident. Further review showed that a caregiver from an adjacent apartment building encountered the resident outside the facility and, after a brief conversation, transported her to her daughter's house without notifying facility staff. The facility's policy required weekly checks of the departure alert system, but staff reported that checks were being done nightly and, after the incident, every shift. The failure to provide adequate supervision and ensure the proper functioning of the departure alert system resulted in the resident's unsupervised exit from the facility.
Failure to Timely Report Resident Bruising
Penalty
Summary
A facility failed to ensure timely reporting of suspected abuse when a certified nursing assistant (CNA) observed a large bruise on a resident's right arm, wrist, and hand during morning care but did not report the finding immediately. The CNA first noticed the bruising at approximately 8:30 AM while assisting the resident with dressing but did not inform anyone at that time due to being busy. The bruising was only reported later in the afternoon to the Social Services Director. According to the facility's policy, injuries of unknown origin, such as bruises, are to be reported immediately to the appropriate personnel.
Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses of weakness, muscle weakness, chronic fatigue, osteoarthritis, and chronic pain was not transferred safely by staff. The resident, who requires one-person assistance and a gait belt for transfers, was found with a large, dark purple/red bruise encircling her right forearm. The resident reported that during a nighttime transfer, a CNA pulled her by the arm to help her out of bed, rather than using the gait belt as required by her care plan. The CNA involved stated it was her first time assisting this resident at night and that she believed the resident could stand with a walker, so she assisted her to stand and then held the gait belt, but did not describe using the gait belt during the initial transfer from bed. Other staff members familiar with the resident confirmed that proper transfer technique involves the use of a gait belt and that the resident should not be pulled by the arms. The facility's policy also requires staff to use gait belts for non-mechanical transfers. The improper handling was corroborated by staff observations and interviews, as well as the resident's own account, which indicated that the transfer was rough but not intentionally abusive. The incident resulted in significant bruising to the resident's forearm.
Failure to Properly Store, Label, and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly manage food storage and labeling in the kitchen. During a kitchen tour, an open bag of turkey breast and an open bag of ham were found in the refrigerator without any open or use by dates. Additionally, a reusable container labeled with the dietary manager's first name and a date, a metal container of potato salad past its use by date, and a whipped topping container with no labels or dates containing black olives were also found. The dietary manager confirmed that the container with her name was her personal item, was unsure how long the olives had been there, and acknowledged that the deli meats and potato salad should be discarded due to lack of proper dating or being past the use by date. The facility's policy requires all items in the cooler to be labeled with the item, initials, date, and use by date, and any improperly stored food to be disposed of immediately. These failures were identified as having the potential to affect all 46 residents in the facility.
Failure to Assess, Obtain Order, and Document Use of Pommel Cushion
Penalty
Summary
A deficiency occurred when a resident was observed seated in a reclining wheelchair with a pommel cushion and non-slip fabric, without prior assessment of the need for this device. The Certified Nursing Assistant (CNA) stated that the cushion was used to prevent the resident from sliding forward and falling out of the chair. The Director of Nursing (DON) was unaware of the cushion's use and confirmed that it was not included in the resident's care plan. The restorative aide reportedly added the cushion due to the resident's seizure disorder and tendency to scoot down in the chair, and the hospice nurse was aware of its use. However, there was no documentation of a physician's order for the cushion, nor was its use reflected in the care plan. The resident in question had multiple diagnoses, including epilepsy, pseudobulbar affect, delusional disorder, abnormal breathing, sleep apnea, hypothyroidism, Down syndrome, pain disorder, and depression. The care plan noted the resident's risk for falls and her behavior of sliding or scooting forward in her wheelchair, but did not include any interventions related to the pommel cushion. The facility's policy defined physical restraints and required that their use be preceded by less restrictive alternatives, informed consent, and a physician's order, none of which were documented in this case.
Failure to Properly Label and Discard Expired Insulin
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and timely disposal of insulin for two residents. During inspection of the medication storage cart, one resident's lispro insulin vial and another resident's novolog insulin vial were both found to be opened and labeled with dates indicating they had been in use for over 30 days, exceeding the facility's policy and manufacturer recommendations for insulin use. Additionally, an opened tresiba insulin pen for the second resident was not labeled with an open date. A registered nurse confirmed that insulin should be labeled with the date opened and discarded after 27 days. Review of physician orders confirmed that these insulins were currently prescribed for the residents. The facility's own policy requires opened insulin to be clearly labeled with the date opened and disposed of after 28 days or per manufacturer instructions.
Failure to Offer and Document Pneumococcal Vaccination Consent
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received the recommended pneumococcal immunization according to current CDC guidelines. The Assistant Director of Nursing/Infection Prevention Nurse stated that vaccines are offered to residents upon admission and annually, including all types of pneumococcal vaccines. Review of the resident's records showed she had previously received PCV-13 and PPV23 vaccines, making her eligible for a dose of PCV20 based on shared clinical decision-making recommendations. However, there was no documentation of consent or refusal for the PCV20 vaccine for this resident. The facility's policy requires that pneumonia vaccines be offered upon admission and annually, with residents or their representatives asked to indicate their wishes regarding the vaccine, but this process was not documented for the resident in question.
Inconsistent Infection Control Practices for Resident with Shingles
Penalty
Summary
The facility failed to implement appropriate infection control interventions for a resident diagnosed with shingles. The resident, who was admitted with multiple diagnoses including Type 2 Diabetes and moderate cognitive impairment, was noted to have clear fluid-filled blisters and was placed on contact precautions. However, inconsistencies were observed in the application of these precautions. On several occasions, the infection notes indicated varying levels of precautions, from standard to contact with cares, and there was a lack of clarity and consistency in the implementation of these precautions. On a specific date, a sign indicating contact precautions was posted on the resident's door, yet visitors and staff were observed entering the room without donning personal protective equipment (PPE). The Director of Nursing and the Infection Preventionist both stated that PPE was only necessary during direct care, contradicting the facility's policy which required contact precautions until lesions were crusted or healed. The facility's policy also specified the need for isolation bins with PPE outside the resident's room, which was not adhered to, leading to a deficiency in infection control practices.
Improper Transfer Practices Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure safe transfer practices for residents, resulting in two incidents involving improper use of equipment and lack of safety measures. In the first incident, a CNA inadvertently pulled the emergency release of a full body mechanical lift while transferring a resident, causing the lift to hit the resident in the face and knock off her glasses. The CNA admitted to pulling the release absentmindedly after dropping the controller, despite there being no emergency. The Director of Nursing confirmed that pulling the emergency release was not standard practice, and the facility's Mechanical Lift Policy emphasized the use of mechanical lifts for safe transfers. In the second incident, a resident fell and hit her head on the toilet during a transfer from the toilet to a wheelchair. The CNA assisting the resident did not use a gait belt, despite the resident's Fall Care Plan indicating its necessity for transfers. The CNA stated she did not use a gait belt for short transfers, although she did use it for bed-to-wheelchair transfers. The Physical Therapist highlighted the importance of gait belts for stabilizing residents and preventing falls. The facility's Gait Belt Policy also underscored the use of gait belts as a safety measure.
Improper Use of Mechanical Sling Lift Causes Resident Injury
Penalty
Summary
The facility failed to safely control a full body mechanical sling lift, resulting in a resident sustaining a laceration to her forehead. The incident involved two Certified Nursing Assistants (CNAs) who were transferring the resident using the mechanical sling lift. During the transfer, the lift tilted, causing a bolt to lacerate the resident's head. The resident was subsequently found with a 5-centimeter wound on her forehead, which appeared to be an abrasion. The resident reported that there were two staff members present during the transfer, and she began bleeding profusely after the incident. The CNAs involved provided conflicting accounts of the incident. One CNA was guiding the resident while the other operated the mechanical lift. The Assistant Director of Nursing (ADON) reported hearing a commotion and found the lift tilted when she entered the room. The CNAs explained that the resident was hooked up on the lift and repositioned in the wheelchair, which caused the lift to tilt. The facility's Mechanical Lift Policy/Procedure requires one staff member to manage the lift while the other supports the resident, ensuring proper positioning over the wheelchair. However, this procedure was not followed, leading to the resident's injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 316 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Durand
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willows Health Center | 14.3 mi | ★★★★★ | 13 | 0 |
| Fair Oaks Rehab & Healthcare | 14.7 mi | ★★★★★ | 26 | 1 |
| River Bluff Nursing Home | 14.8 mi | ★★★★★ | 6 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 15 mi | ★★★★★ | 0 | 0 |
| Amberwood Care Centre | 15 mi | ★★★★★ | 2 | 0 |
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